Failure to Notify Law Enforcement of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse involving two residents was reported to law enforcement as required by facility policy and regulatory expectations. The facility’s Abuse/Neglect/Exploitation policy, dated 11/2017, states that all alleged violations are to be reported to the Administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable, within specified timeframes. A misconduct incident report submitted on 12/30/25 documented that one resident (R4), who had dementia with severe cognitive impairment per an admission MDS assessment, slapped another resident (R3) in the face while R3 was sitting in the lobby and R4 was walking to the dining room. Staff witnessed the event, immediately intervened, and nursing assessed R3, with no injuries noted. The incident report identified R3 as the affected person and R4 as the accused person. The same misconduct incident report indicated that law enforcement was not contacted regarding this resident‑to‑resident altercation. During an interview on 1/21/26, the Nursing Home Administrator (NHA A), who prepared and submitted the misconduct incident report, stated that law enforcement should be notified with every facility self‑report and acknowledged that law enforcement had not been notified for this incident and that it “should have been,” attributing the omission to it having been forgotten. As a result, the alleged abuse incident involving R3 and R4 was not reported to law enforcement in accordance with the facility’s written procedures and reporting requirements.
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